The Claims Management Experience

Leave a Comment
November 15th, 2013

Claims Management

PayerFusion: Building The Claims Management Experience

When PayerFusion’s claims management department receives a claim from one of the providers in its network or an affiliated insurer, the ball gets rolling fairly quickly. While claims arrive from all over the globe, some simple, some complex, our claims management team will always ensure the fairest price is attained for the highest quality care.

Firstly, all involved parties are notified regarding the claims status and this continues throughout the process. Simultaneously, the appropriate steps are taken to validate the claim on all fronts – patient data, provider info, insurance policy details, billing and medical coding, fraudulent or duplicate statuses, etc. The process is upheld by full coordination and collaboration.

The claim is then entered into a claims management system where we can begin evaluating costs and charges, before applying our unique cost-plus model to generate a reimbursement figure for negotiation. While this goes on, our case managers remain in contact with patients, payers, and providers, updating them on the status of the claim or case, and offering as much assistance as possible, even to the extent of arranging transportation or translations services for the patient.

To add to this process, PayerFusion provides multiple tools for all parties to monitor the progress of each claim or case such as a global provider search, access to an online claims process, 24/7 call-center assistance and more.

PayerFusion’s claims management team is structured to ensure that the fairest price is achieved for the highest quality medical service, providing the patient, provider, and payer peace of mind throughout the entire process.

By designing the claims management process this way, PayerFusion is able to stand out amongst other TPA’s, health plan administrators, and industry competitors worldwide through building a unique medical experience for each patient.

Changing The Industry

The current health insurance landscape is in an outcry for innovation, and claims management should be included amongst the focal points of its reform. A recent survey by Curaspan of more than 100 community hospital CEOs, assessing the strategic value of certain functions in each of their facilities, pin-pointed claims management as the second most valuable function.

If the industry is to not only meet the demands of payers and providers, but also patients, there needs to be a greater emphasis on the importance of claims management, especially with the rapidly approaching shake-up under the PPACA.

While the claims management process will become even more complicated under the reforms to healthcare, the solution remains simple – patient-centered. By aligning the patient as the focal point of the process and then collaborating with all other parties involved to meet the demands of each specific case, the claims management process shifts towards offering a successful medical experience versus a service or procedure.

In re-evaluating your own claims management team, consider the following issues:

  • Unique patient demands and requirements outside of healthcare reform.
  • Changing demands of both providers and payers under healthcare reform.
  • Integration and collaboration of data and reporting between all parties.
  • Integrating behavioral, medical, and rehabilitative services.
  • Expanding patient support beyond clinical settings and into the community.
  • Utilizing information systems and technology to open lines of communication; gather, analyze, and share data or info; and engage all parties including patients, payers, and providers.
  • Finally, the claims management process extends beyond the patient receiving treatment and should empower patients towards achieving their desired outcomes under the support of insurance companies and medical providers.

As an intangible service, claims management must ultimately be about relationship building and outcomes, not profits and expenses.

To learn more about the claims management experience with PayerFusion visit our website at or call 1 (305) 760-8739.